Gladys Strain

Laparoscopic sleeve gastrectomy: does bougie size affect mean %EWL? Short-term outcomes

BACKGROUNDnLaparoscopic sleeve gastrectomy (LSG) has been increasingly offered to high-risk bariatric patients as the first-stage procedure before gastric bypass or biliopancreatic diversion or as the primary weight loss procedure. The bougie size has varied by surgeon during LSG. The aim of this study was to determine whether short-term weight loss correlates with the bougie size used during creation of the sleeve.nnnMETHODSnWe retrospectively reviewed the data from all patients who had undergone LSG at our institution between 2003 and 2006. Revision LSG for failed bariatric procedures was excluded. The data analyzed included preoperative age, body mass index (BMI), bougie size, and percentage of excess weight loss (%EWL).nnnRESULTSnA total of 135 patients underwent LSG during the 4-year period. Most of these patients (79%) underwent LSG as part of a 2-stage operation (either gastric bypass or duodenal switch within a mean of 11 months). The mean preoperative age and BMI was 43.5 years and 60.1 kg/m(2), respectively. The mean BMI and %EWL at 6 months was 47.1 kg/m(2) and 37.9%, respectively. The mean BMI and %EWL at 12 months was 44.3 kg/m(2) and 47.3%, respectively. When stratifying the %EWL by bougie size (40F versus 60F), we did not find a significant difference at 6 months (38.8% versus 40.6%, P = NS) or 12 months (51.9% versus 45.4%, P = NS).nnnCONCLUSIONnLSG results in significant weight loss in the short term. When stratifying outcomes by bougie size, our results suggested that a bougie size of 40F compared with 60F does not result in significantly greater weight loss in the short term. However, longer follow-up of the primary LSG group is required to determine whether a difference becomes evident over time.

Increased PTH and 1.25(OH)2D Levels Associated With Increased Markers of Bone Turnover Following Bariatric Surgery

The objective of this study was to characterize changes in metabolic bone parameters following bariatric surgery. Seventy‐three obese adult patients who underwent either gastric banding (GB), Roux‐en‐Y gastric bypass (RYGB), or biliopancreatic diversion with duodenal switch (BPD/DS) were followed prospectively for 18 months postoperatively. Changes in the calcium‐vitamin D axis (25‐hydroxyvitamin D (25OHD), 1,25‐dihydroxyvitamin D (1,25(OH)2D), calcium, parathyroid hormone (PTH)), markers of bone formation (osteocalcin, bone‐specific alkaline phosphatase) and resorption (urinary N‐telopeptide (NTx)), as well as bone mineral density (BMD) were assessed at 3‐month intervals during this time period. Bariatric surgery resulted in significant and progressive weight loss over 18 months. With supplementation, 25OHD levels increased 65.3% (P < 0.0001) by 3 months, but leveled off and decreased <30 ng/ml by 18 months. PTH initially decreased 21.4% (P = 0.01) at 3 months, but later approached presurgery levels. 1,25(OH)2D increased significantly starting at month 12 (50.3% increase from baseline, P = 0.008), and was positively associated with PTH (r = 0.82, P = 0.0001). When stratified by surgery type, median PTH and 1,25(OH)2D levels were higher following combined restrictive and malabsorptive operations (RYGB and BPD/DS) compared to GB. Bone formation/resorption markers were increased by 3 months (P < 0.05) and remained elevated through 18 months. Radial BMD decreased 3.5% by month 18, but this change was not significant (P = 0.23). Our findings show that after transient improvement, preoperative vitamin D insufficiency and secondary hyperparathyroidism persisted following surgery despite supplementation. Postoperative secondary hyperparathyroidism was associated with increased 1,25(OH)2D levels and increased bone turnover markers.

Medical versus surgical treatment of type 2 diabetes: the search for level 1 evidence.

Data from observational and nonrandomized comparative studies have shown a dramatic effect of bariatric surgery on type 2 diabetes mellitus (T2DM), including in nonobese patients. However, a relative paucity of level 1 evidence is available to define the exact role of surgery as a treatment modality for T2DM, especially in less obese subjects. Performing randomized clinical trials in this field, however, poses significant and specific challenges for the study design. We have addressed such challenges in a carefully designed randomized controlled trial comparing glycemic control with optimal medical management versus Roux-en-Y gastric bypass in overweight to mildly obese patients with T2DM mellitus (body mass index 26-35 kg/m(2)). The present report describes the rationale and design of the Weill Cornell Medical College study. In addition to glycemic endpoints, however, clinical trials should also investigate the effect of surgery on cardiovascular risk or T2DM-specific morbidity. Addressing these endpoints would entail large, randomized clinical trials with prolonged period of observation and ideally a multicenter study design. Such a multisite trial poses substantial logistical and financial challenges, which would predictably delay rather than accelerate progress of research in this field. A consortium of centers performing independent small and medium size randomized clinical trials may provide a more realistic and feasible approach. In this paper, we present an overview of on-going randomized clinical trials in this field and propose a worldwide consortium of randomized controlled trials (WORLDCoRDS) using the Weill Cornell Medical College protocol. The aim of this consortium is to standardize research in T2DM surgery and timely accumulate homogeneous data that can help assess the effects of GI surgery on cardiovascular risk and T2DM-related mortality and morbidity.